By Fikre Germa, MD FCFP
The complexity and uncertainty of dealing with Covid-19 has challenged all of us in clinical education programs. In the regional acute health centre where I am a hospitalist, our family medicine residents were initially concerned about their clinical practice. As a preceptor, so was I. Day in, day out my students and I implicitly and, at times, explicitly, explored what it means to live and learn medicine in the time of a pandemic.
Yet, in the midst of our fear and frustration, we valued each other as learner and preceptor doing medicine. The residents treated the pandemic as a challenge to be overcome, a new disease to understand, and an opportunity to find new ways of practising medicine.
As I reflected on what could possibly be the best, the bad and the good in learning medicine during this pandemic, I realized I could build on the residents’ reactions to the crisis. They quickly adapted to treating patients while wearing personal protective equipment and social distancing, an antithesis to how we usually practise medicine. It was unsettling to have to communicate only with our eyes.
Psychologically, they were more open to learning why both science and story matter in patient care. As a result, hospitalist medicine became an ideal space of learning for further equipping them to take a holistic approach to patient care, to provide comprehensive care.
During the pandemic, our team’s comfort with discussions helped us grow as a team. Fostering curiosity in residents equips them with an orientation and key competency that makes learning and teaching an enriching experience. I have found over my 15 years as a preceptor that the best residents are endlessly curious and ask questions. They are always willing to give the diagnosis the benefit of the doubt and ask: Am I missing something here; what else could it be? During a crisis, curiosity helps us be imaginative about possible scenarios and solutions and reflect on what is important to our patients. Students come up with fresh ideas, using a different lens than the preceptor to solve a problem, perhaps with a more efficient use of technology.
The challenges of doing medicine in a pandemic reinforced the importance of fostering residents’ ccompassion and humility. The late Peter Frost, a professor of organizational change, wrote in “Why Compassion Counts:”1
To act with compassion requires a degree of courage—one must often go beyond the technical, the imperative, the rules of organizations and beyond past practise — to invent new practices that have within them empathy and love and a readiness to connect to others. There is a creativity, a spontaneity, and a very special attunement that accompany a desire to act with empathy engendered by a sympathetic consciousness of another’s distress (Benner, Tanner, & Chesla, 1996) (page 129).
Covid-19 provided an ideal environment for me, as a preceptor, to work from medicine’s “hidden curriculum” to transmit norms and integrate values. In her article, “Medical education: Beware the hidden curriculum,”2 Sally Mahood warns about the potential dangers of the hidden curriculum: she says, that it “undermines us as caring and ethical professionals. Collegiality, patient-centred care, and ethical practice are often subordinated for factual knowledge or are brushed aside by practical realities.”
However, as Mahood said, we can “make the hidden curriculum and its messages a topic of explicit discussion and strive to model different messages.” In this time of pandemic, reflecting on the connections of illness, poverty, and global health is vital.
While patients who come into hospitals receive excellent care in the Canadian healthcare system, the disadvantaged may not have the same outcomes as those enjoying good determinants of health. Covid-19 made the residents more aware of how social inequities and emotional insecurity affected patients. My residents can rehash the critical importance of the social detriments of disease. They know that a lack of housing and social inequality have an adverse effect not only on the vulnerable and their families but also on our communities and countries. They know that a patient’ postal code, their neighbourhoods, is a deciding factor of health outcomes and ask themselves what can be done. In the hospital, the best they can generally do is involve a social worker in the hope that professional can help the person find housing and social supports.
During our discussions, I would raise the issue of advocacy in patient care. In an editorial entitled, “The Fifth Principle. Family Physicians as Advocates,”3 Carol Herbert, a professor of medicine, wrote that the doctor of the 21st century will have to be politically engaged and advocate for patients and the system. “They must partner with patients, to build public capacity to question and confront the implications of decisions taken by governments, health care and educational institutions, and professional organizations, for the health of individuals and the population.” How right she was.
Yet, our standard forms of advocacy may have limitations. We need to consider whether a patient has the capacity to follow a recommendation, for example, to attend the addiction team or fill in a 30-page document in order to receive support. In Scarcity: Why Having Too Little Means So Much,4 Sendhil Mullainathan and Eldar Shafir suggest that when a person is stressed because of a lack of resources, their brain is unable to deal with a cognitive load. This leads to tunnel vision and narrowed solutions to problems. This conceptualization, which needs to be further explored, has enabled me to better understand the choices that disadvantaged people make. It further suggests that as advocates we may need to adopt innovative thinking about social determinants of health so we discharge patients with the right framework of interventions.
The pandemic reinforced the need for residents to have more exposure to global health thinking. Family physicians to understand this key concept because, as was so quickly evident with Covid-19, what happens elsewhere can affect us locally. Diseases now cross our borders, crossing vast geographical areas in a few hours because of our interconnections. In the article “Developing Family Practice to Respond to Global Health Challenges,”5 the authors frames global health conceptually, giving family physicians an understanding of the skill sets needed to engage global health. Equipping medical students to think globally will better prepare them to learn and understand disease processes in terms of systems. This is crucial because then we can understand causation and prevention and our advocacy will better serve the interests of the patient, the community and the country.
This pandemic has been a wake-up call. It reinvigorated our passion to medicine, our commitment to patient care and patients, to continue to trigger this in us as teachers to continue to value the importance of social justice, global health and health equity and commitment to excellence. In the years to come, the conversation about healthcare is going to also refocus the conversation on these issues so we can play a more holistic care for our patients and communities.
In summary, I hope the pandemic has triggered us as preceptors to refocus on the critical importance of global health and innovative thinking and systems thinking in nurturing our students toward commitments to goodness, excellence, ethics, and respectability.
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